Medicinal Marijuana Long Island

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Are you currently taking any medications? *

Are you allergic to any medications? If so, please specify. *

How did you hear about Medicinal Marijuana LI? *

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How may I contact you? *

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Scan of New York State Driver's License or State ID *

What conditions are you seeking medicinal marijuana for? Presently or in the past. *

(example: HIV/AIDS, chronic pain, PTSD, seizures, anxiety, insomnia, weight loss, nausea, muscle spasm, migraine headaches, decreased appetite, ALS/Lou Gehrig's, Parkinson's, Huntington's, Multiple Sclerosis, spinal cord injuries, opiate use, fibromyalgia)

What symptoms are you having? *

Surgical History: Please list all surgeries and the date occured *

Please discuss the the non-surgical treatments you have received or are presently receiving for your medical condition(s) *

Have you ever been hospitalized for the above conditions? Where, when and for how long? *

Do you have a primary care provider? Have you discussed the above symptoms? *

Is there a family history of mental illness, i.e. parents, grandparents, siblings, aunts, uncles? *

Have you ever been diagnosed with any of the following mental health issues: ADHD, bipolar disorder, depression, schizophrenia, suidical thoughts? *

Are there any activities that you are severely limited in doing or totally impaired (i.e. ability to do, strength, weakness, pain) by one of the conditions above for which you are seeking medicinal marijuana? *

Do you smoke or chew tobacco? *

Do you have any history of substance abuse or present addictions? *

Have you used cannabis prior, to self-medicate? *

Are there any health issues that run through your family? (BP/stroke/diabetes)? *

Have you ever had any adverse reactions from cannabis use? *

Do you have any medical records that document your medical conditions with you? *

Is there anything you deem important to this evaluation? *

If you have any medical records to upload, please do so here.

Please read each item below and click the button at the end of each statement and the entire form to confirm your knowledge of the information pertaining to the benefits, risks, and side effects of using medicinal marijuana. I will agree to tell the NP/MD if I do not understand any of the information given to me.

Marijuana varies in potency. The effects are also dependent upon the delivery system. Calculating the precise medicinal marijuana dose is a very important part of the process. Symptoms of medicinal marijuana overdose include, but are not limited to: vomiting, cough, nausea, heart rhythm irregularities, and numbness and tingling to the limbs. *

I agree
I do not agree

The efficacy and potency of medicinal marijuana can vary greatly depending on the choice of delivery, and the strain. Under federal law, the NP/MD is unable to discuss dosage. *

I agree
I do not agree

I agree to use birth control while using medicinal marijuana. In the event I become pregnant, I will agree to immediately discontinue medicinal marijuana and contact my NP/MD ( females only) *

I agree
I do not agree

Cannabis is not regulated by the USFDA, and therefore may contain unknown quantities of active ingredients, impurities and or contaminants *

I agree
I disagree

I intend to obtain and use medicinal marijuana in the State of New York for my medical condition should it be recommended by NP/MD. *

I agree
I do not agree

I understand that side effects may occur while I am taking my medicinal marijuana which can include, but are not limited to; dry mouth, poor physical concentration, short term memory loss, irregular heartbeat, cough, hunger, loss of appetite, dizziness, anxiety/ nervousness, decreased reaction time, headaches, confusion, apathy, drowsiness, feeling euphoria, impaired vision, dependency, change in sleep patterns, numbness, laryngitis, agitation, irritability, depression, trouble concentrating, high/low blood pressure, sedation, difficulty concentrating and finishing tasks, inability to concentrate, paranoia, psychotic behaviors (delusions, hallucinations), suppression of immune system, impairment of motor skills (i.e. coordination, reactionary time), extreme talkativeness. *

I agree
I do not agree

I understand fully that there may be benefits and risks associated with medicinal marijuana use that have not been identified. *

I agree
I do not agree

If I start taking medicinal marijuana, I agree to immediately tell my NP/MD if I start feeling like I am losing interest in my usual activities, if I start feeling sad and have crying spells, notice changes in my sleep pattern, lose my appetite, withdraw from family and friends, become more irritable than usual, become pregnant, or become exhaustingly tired. *

I agree
I do not agree

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I confirm that the above information provided by me regarding my diagnosis and medical records is true and correct. *

I agree
I do not agree

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